- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $228.45 / $239.86 / $239.86
| Facility | | $228.45 | $239.86 | $239.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.86 / $239.86 / $239.86
| Professional | | $239.86 | $239.86 | $239.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $160.35 / $160.35 / $240.52
| Facility | | $160.35 | $160.35 | $240.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.35 / $160.35 / $163.56
| Professional | | $160.35 | $160.35 | $163.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.38 / $263.38 / $263.38
| Facility | | $263.38 | $263.38 | $263.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.38 / $263.38 / $263.38
| Professional | | $263.38 | $263.38 | $263.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.75 / $265.73 / $282.19
| Professional | | $225.75 | $265.73 | $282.19 |